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Chapter 7. Implementation

Smallpox Vaccination Program Support Service

Following the Presidential Order of December 13, 2002, to vaccinate emergency medical hospital staff against the smallpox virus, the Colorado Department of Public Health and Environment (CDPHE) implemented Phase I of the Colorado Smallpox Vaccination Plan. The CDPHE contracted with Denver Health Medical Information Centers (DHMIC) to provide support telephone lines to the public via the Colorado Health Emergency Line for Public (CO-HELP) and to vaccine recipients and their health care providers via the Colorado Provider & Hospital Information Line (CO-PHIL) during implementation of the smallpox vaccination program. This was recognized as an opportunity to test some components of the Health Emergency Assistance Line and Triage Hub (HEALTH) model.

The service provided general smallpox information to the public and specific vaccine information to vaccine recipients and their health care providers. The service collected Vaccine Adverse Events Report Surveillance (VAERS) data on behalf of CDPHE and the Centers for Disease Control (CDC). The service also provided trained nurses to offer decision support and referrals to vaccine recipients who were experiencing vaccine-related adverse events using CDC approved clinical decision trees. A diagram of the information flow delivered in this service is available in Appendix E, and a sample report made to the State health department is in Appendix C.

With approximately 1 month to plan for the event, the DHMIC hired a call center manager and five information specialists. The rapid ramp-up of the service allowed DHMIC to approximate the response to a public health emergency event. Calls were routed to our center using the CO-HELP and CO-PHIL toll-free numbers via a total of four dedicated emergency T-1 lines (each T-1 is made up of 24 telephone lines). These telephone numbers and T-1 lines had been installed in early 2002. Callers received information provided by the CDPHE and CDC through a recorded message with the option to speak to an information specialist afterwards. Information specialists documented types of questions asked by callers, information given, and required data for vaccine adverse events. They also offered referral to on-call physicians, State and national epidemiologists, and infectious disease specialists. Registered nurses provided medical decision-making assistance using the CDC clinical decision trees. The need for new required information arose on two occasions. The first occurred when an ophthalmic inoculation occurred. This prompted the CDC to develop a new clinical decision tree. The second need arose when military vaccine recipients emerged as a special population that requested service through this program.

CO-HELP and CO-PHIL received 193 calls between January 28 and April 26, 2003. Of these, 116 called via CO-HELP and 77 called via CO-PHIL. Of all 193 calls, 76 callers (39 percent) spoke with a live agent. The most common questions asked by callers are summarized in Table 3. Adverse events were reported in 12 cases. Ten of those cases were civilian, and two were military vaccine recipients. A summary of the adverse events reported is presented in Table 4.

After I am vaccinated, how long do I need to wait to donate sperm/blood, take steroids, etc.?

5 (7%)

Should my children be vaccinated?

3 (4%)

Other

24 (31%)

Table 4. Adverse Events Reported to CO-PHIL (N = 12)

Adverse Events

No. (%)

Contact inoculation

3 (25%)

Ophthalmic inoculation

3 (25%)

High blood pressure w/ visual symptom

2 (16%)

Encephalitis

1 (8%)

Generalized vaccinia

1 (8%)

Neurologic symptoms

1 (8%)

Localized reaction

1 (8%)

West Nile Virus

During the summer of 2003, Colorado was hit with the worst outbreak of WNV yet experienced in the United States. By the end of September, 42 people had died and 2,013 people had serologically confirmed infections. Anticipating the spread of WNV in the State, CDPHE contracted with us to provide a WNV hotline. CO-HELP went into operation on July 22, 2003 and was available through October 13, 2003.

Our basic level of service, staffed by information specialists and delivered via CO-HELP, was implemented for public support during the WNV outbreak. Callers listened to a recorded message and afterwards were instructed to stay on the line to speak with an information provider. The information specialists answered questions using Frequently Asked Questions (FAQs) that had been developed by State epidemiologists. We designed a Public Health Information Program within the LVM e-Centaurus Software used in our NurseLine to assure accurate and consistent delivery of this information. The design was built on a database containing State approved FAQ information and used embedded decision trees to assure that information specialists responded to call types appropriately. Ongoing updates were communicated as required. A dead bird survey was developed to support counties that were overwhelmed doing dead bird surveillance. During the smallpox vaccination support program, we collected county data only from callers. During WNV per county requests, we collected zip code and city as well. Calls were received from 54 Colorado counties (84 percent), 33 other States, and Canada.

Reports were produced in Excel and sent to CDPHE in encrypted E-mails. Early on in the program some counties saw the value of the data collection and requested county-, zip code-, and city-specific dead bird reports to support their surveillance efforts.

By September 30, 2003, we had received 12,227 calls. Forty-five percent of callers listened to the recorded message only; 3 percent hung up while on hold for a live agent; and a live agent handled the majority, 52 percent, of calls. We began the program with 223 FAQs and had to add 21 additional ones to meet caller requests, ending with 244 FAQs. The frequency of top FAQ categories is listed in Table 5, and the frequency of the top 10 questions asked by callers is summarized in Table 6.

Table 5. Frequency of Top FAQ Categories (N = 6687, callers who spoke with a live agent)

Top Categories

%

Dead bird report

41.6%

General information call

25.5%

Possible human WNV case

20.6%

Other

9.6%

Possible animal WNV case

1.3%

Callback

0.7%

Health professional, nurse, doctor

0.6%

Media request

0.1%

E-mail information back to caller

0.1%

Table 6. Frequency of Top 10 Questions Asked By Callers (N = 131)

Top 10 Questions

No. (%)

What are the symptoms of WNV?

1318 (38.8%)

How can I protect myself from WNV?

740 (21.8%)

I found a dead bird; is it likely to have died from WNV?

422 (12.4%)

How can I safely handle a dead bird?

209 (6.2%)

Can birds pass WNV directly to humans?

152 (4.5%)

Why have some areas stopped testing dead birds?

149 (4.4%)

Will a WNV infection protect me from future infections?

128 (3.8%)

How should I deal with dead birds on my property?

120 (3.5%)

Can my dog/cat get WNV?

88 (2.6%)

Is there a mosquito control program in my area?

73 (2.2%)

We summarized our call metrics for CO-HELP during the WNV hotline period (Table 7). We used the same categories of metrics that are used by the broader call center industry. It is important to note that while we could report these metrics, no direct comparisons should be made due to the significantly specialized nature and circumstances of the WNV hotline. For example, there are training differences between a "hotline" and a full-blown call center operation, with the former being more specialized and emergent. In addition, without known call volumes as is the case with an emergency hotline, we were pleased to meet some, and come close to other, metrics set for a contact center that does standard work with predictable call volumes. We had the advantage of being within a well-equipped call center environment, which allowed us to gather metric information not normally gathered by hotlines. We are using the call data to begin the normal call forecasting.